Embed Size (px)
Citation preview
1
COA- Achilles Tendon Ruptures
Timothy Charlton MD USC Dept of Orthopaedic Surgery
Asst Professor USC Keck School of Medicine Foot and Ankle Surgery
2
No Disclosures
3
ldquoI donrsquot get nothing from nobody including my wiferdquo
-Bill Hamilton
4
Achilles Rupture
5
ldquohellipthis tendon (Achilles) if bruised or cut
causes the most acute fevers induces choking deranges the mind and at length
brings deathrdquo
-Hippocrates
Response to Injury
6
Achilles Anatomy
bull Spirals 90 degrees bull Collagen I and Elastin bull Surrounded by paratenon
7
Achilles Anatomy Blood Supply
bull Musculotendinous junction bull Bone-Tendon junction bull Paratenon bull Anterior vascular bed
8
Achilles Anatomy Blood Supply
bull Relative avascular zone between 2cm and 6cm proximal to the tendon insertion
bull ldquoWatershed Zonerdquo
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
2
No Disclosures
3
ldquoI donrsquot get nothing from nobody including my wiferdquo
-Bill Hamilton
4
Achilles Rupture
5
ldquohellipthis tendon (Achilles) if bruised or cut
causes the most acute fevers induces choking deranges the mind and at length
brings deathrdquo
-Hippocrates
Response to Injury
6
Achilles Anatomy
bull Spirals 90 degrees bull Collagen I and Elastin bull Surrounded by paratenon
7
Achilles Anatomy Blood Supply
bull Musculotendinous junction bull Bone-Tendon junction bull Paratenon bull Anterior vascular bed
8
Achilles Anatomy Blood Supply
bull Relative avascular zone between 2cm and 6cm proximal to the tendon insertion
bull ldquoWatershed Zonerdquo
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
3
ldquoI donrsquot get nothing from nobody including my wiferdquo
-Bill Hamilton
4
Achilles Rupture
5
ldquohellipthis tendon (Achilles) if bruised or cut
causes the most acute fevers induces choking deranges the mind and at length
brings deathrdquo
-Hippocrates
Response to Injury
6
Achilles Anatomy
bull Spirals 90 degrees bull Collagen I and Elastin bull Surrounded by paratenon
7
Achilles Anatomy Blood Supply
bull Musculotendinous junction bull Bone-Tendon junction bull Paratenon bull Anterior vascular bed
8
Achilles Anatomy Blood Supply
bull Relative avascular zone between 2cm and 6cm proximal to the tendon insertion
bull ldquoWatershed Zonerdquo
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
4
Achilles Rupture
5
ldquohellipthis tendon (Achilles) if bruised or cut
causes the most acute fevers induces choking deranges the mind and at length
brings deathrdquo
-Hippocrates
Response to Injury
6
Achilles Anatomy
bull Spirals 90 degrees bull Collagen I and Elastin bull Surrounded by paratenon
7
Achilles Anatomy Blood Supply
bull Musculotendinous junction bull Bone-Tendon junction bull Paratenon bull Anterior vascular bed
8
Achilles Anatomy Blood Supply
bull Relative avascular zone between 2cm and 6cm proximal to the tendon insertion
bull ldquoWatershed Zonerdquo
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
5
ldquohellipthis tendon (Achilles) if bruised or cut
causes the most acute fevers induces choking deranges the mind and at length
brings deathrdquo
-Hippocrates
Response to Injury
6
Achilles Anatomy
bull Spirals 90 degrees bull Collagen I and Elastin bull Surrounded by paratenon
7
Achilles Anatomy Blood Supply
bull Musculotendinous junction bull Bone-Tendon junction bull Paratenon bull Anterior vascular bed
8
Achilles Anatomy Blood Supply
bull Relative avascular zone between 2cm and 6cm proximal to the tendon insertion
bull ldquoWatershed Zonerdquo
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
6
Achilles Anatomy
bull Spirals 90 degrees bull Collagen I and Elastin bull Surrounded by paratenon
7
Achilles Anatomy Blood Supply
bull Musculotendinous junction bull Bone-Tendon junction bull Paratenon bull Anterior vascular bed
8
Achilles Anatomy Blood Supply
bull Relative avascular zone between 2cm and 6cm proximal to the tendon insertion
bull ldquoWatershed Zonerdquo
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
7
Achilles Anatomy Blood Supply
bull Musculotendinous junction bull Bone-Tendon junction bull Paratenon bull Anterior vascular bed
8
Achilles Anatomy Blood Supply
bull Relative avascular zone between 2cm and 6cm proximal to the tendon insertion
bull ldquoWatershed Zonerdquo
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
8
Achilles Anatomy Blood Supply
bull Relative avascular zone between 2cm and 6cm proximal to the tendon insertion
bull ldquoWatershed Zonerdquo
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
9
Achilles Peak Forces
125 X body weight
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
10
Length and What Happens
Physiologic 0
10
20
30
40
1
2
3
4
5
6
7
8
9
10
Stra
in
Physiologic Overuse Rupture
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
11
Muscle Force Elasticity Mismatch
0
10
20
30
40
50
60
10 yo 20 yo 30 yo 40 yo 50 yo 60 yo 70 yo
Elasticity
Muscle
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
12
Achilles Exam
bull Thompson Test bull Palpable Defect bull Contralateral Sag bull STAMP- and nd aintain lantarflexion
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
13
Achilles Rupture Treatment Goals
bull Normal Resting Length bull Minimal Complications bull Get the Ends to Touch and Stay Touching bull Avoid Re-rupture bull Avoid Infection
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
14
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
15
Achilles Tendon Infection is a LIFE changing event
Sterile Technique Similar To Total Joint Arthroplasty
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
16
Blickrsquos Resting Tension Curve
01020304050607080
TooLoose
IdealTension
TooTight
Power
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
17
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
18
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
19
Blickrsquos Resting Tension Curve Target Operative Tension
01020304050607080
TooLoose
IdealTension
TooTight
Power
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
20
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
21
Achilles Rupture Treatment Options
bull Open Treatment bull Cast Dynamic Brace bull Percutaneous bull Minimally invasive
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
22
Expectation Management
1 Year
0
2
4
6
8
10
12
Smart Typical Dumb
Praise Complaints What You Told Them How Long It Takes
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
23
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vsClosed Overall Complications
Favors Non Operative
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
24
Meta Analysis Achilles Rx Khan et al JBJS 2005
0 5
10 15 20
25
30
35
Skin Stiffness Nerve Injury Infection Rerupture
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
25
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open Vs Closed Rerupture
Favors Surgery
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
26
Open vs Closed Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30 35
Open Closed
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
27
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Open vs Perc Reruptures
Favors Percutaneous
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
28
Open vs Percutaneous Achilles Rx Meta-Analysis
Khan et al JBJS 2005
0 5
10 15 20 25 30
Open Percutaneous
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
29
From Treatment of Acute Achilles Tendon Ruptures A Meta-Analysis of Randomized Controlled Trials
J Bone Joint Surg Am 200587(10)2202-2210 doi102106JBJSD03049
Cast vs Functional Bracing
Favors Bracing
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
30
Post-Operative Casting vs Bracing Achilles Rx
Meta-Analysis Khan et al JBJS 2005
0
5
10
15
20
25
30
35
40
Cast F(x) Bracing
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
31
From Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
J Bone Joint Surg Am 201092(17)2767-2775 doi102106JBJSI01401
Open Vs Closed
Favors Operative
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
32
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
33
AOFAS Specialty Day 2013 Baumhauer et al
bull 26000 surgery in ABOS Oral Exam bull Foot and Ankle Surgery had higher risk of
complications vs other body parts bull 841 infection rate Achilles tendon
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
34
ldquoAnd the Survey Saysrdquo
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
35
Charltonrsquos Way
bull Achillon bull Bilateral drape prone position bull Cheat 5 to 10 degrees too tight bull Judge at 45 knee flexion
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
36
Achilles Rupture Sign the BACK of the Leg
Put the tourniquet on before you flip
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
37
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
38
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
39
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
40
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
41
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
42
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
43
Achilles Rehab Thordarson Open Charlton Achillon
bull Plantar Flexion Cast bull NWB 2 weeks bull Passive to Neutral on
Week 3 bull WBAT w heel lift in
cam walker up to week 6
bull Felt heel lift in a shoe on week 6
bull Plantar Flexion Cast for 4 weeks
bull Cam Walker in Plantar Flexion for 4 Weeks PWB
bull WBAT in Cam Walker at Week 8
bull Cowboy Boot for 4 weeks until week 12
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
44
Achilles ldquoBirthdayrdquo
01020304050607080
TooLoose
IdealTension
TooTight
Power
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
45
Oops Somebody Missed It
16th of Achilles Ruptures Are Missed By the 1st Physician Who Exams The
Patient
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
46
Chronic Rupture
bull Small gap- primary repair bull Medium gap- VY lengthening bull Large gap- FHL transfer
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
47
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
48
NVB
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
49
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
50
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
51
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
52
From Management of Chronic Ruptures of the Achilles Tendon J Bone Joint Surg Am 200890(6)1348-1360 doi102106JBJSG01241
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
53
Conclusion
bull Surgery vs Non-operative remains controversial
bull Balance the tension bull Avoid the big complicationsmdashrerupture and
infection bull Get the correct diagnosis
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
54
Thank you
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
55
Achilles Tendon Ruptures
Exam Questions
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
56
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 2Reconstruction with hamstring autograft 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 Achilles repair augmented with transfer of the extensor digitorum longus 5 Achilles repair augmented with transfer of the flexor hallucis longus
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
57
A 62-year-old tennis player ruptured his achilles tendon 12 months ago He initially chose non-operative treatment but continued to have weakness and difficulty ambulating During surgery extensive debridement there is a 4cm gap between viable tissue ends Which of the following surgical techniques most likely will provide the best clinical outcome 1 Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program 1 2Reconstruction with hamstring autograft 6 3 Achilles repair augmented with transfer of the posterior tibial tendon 4 4 Achilles repair augmented with transfer of the extensor digitorum longus 3 5 Achilles repair augmented with transfer of the flexor hallucis longus 86 bull Will RE Galey SM Outcome of single incision flexor hallucis longus
transfer for chronic achilles tendinopathy Foot Ankle Int 2009 Apr30(4)315-7
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
58
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
59
What is the biggest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks 1 Lower rate of infection 2 Lower rate of nerve injury 3 Better skin cosmesis 4 Lower rate of DVT VTE 5 Lower rate of re-rupture 1 Bhandari M Guyatt GH Siddiqui F et al Treatment of acute Achilles tendon ruptures A systematic overview and metaanalysis Clin Orthop Relat Res 2002400190-200 2 Khan RJ Fick D Keogh A et al Treatment of acute Achilles tendon ruptures A meta-analysis of randomized controlled trials J Bone Joint Surg Am 2005872202-2210 3 Willits K Amendola A Bryant D Mohtadi NG Giffin JR Fowler P Kean CO Kirkley A Operative versus nonoperative treatment of acute Achilles tendon ruptures a multicenter randomized trial using accelerated functional rehabilitation J Bone Joint Surg Am 2010 Dec 192(17)2767-75 4 Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
60
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 2 immediate surgery 3 male gender 4 age over 40 years old 5 tobacco use
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
61
Which factor increases the chance of wound complications after Achilles tendon repair 1 increased body mass index 5 2 immediate surgery 3 3 male gender 1 4 age over 40 years old 1 5 tobacco use 91 1 Bruggeman NB Turner NS Dahm DL Voll AE
Hoskin TL Jacofsky DJ Haidukewych GJ Wound complications after open Achilles tendon repair an analysis of risk factors Clin Orthop Relat Res 2004 Oct(427)63-6
Orthobullets
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
62
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
63
Which factor increases the chance of DVTVTE after Achilles tendon repair 1 Obesity 2 Non operative treatment 3 Previous history of DVTVTE 4 Age over 40 years old 5 None of the Above
Patel A Ogawa B Charlton T Thordarson D Incidence of deep vein thrombosis and pulmonary embolism after Achilles tendon rupture Clin Orthop Relat Res 2012 Jan470(1)270-4
